Teaming with Providers: Incentives to Achieve Results
When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs), and Accountable Care Organizations (ACOs).
As health plans continue adapting to the growing influence of clinical quality on their provider network operations, building an effective team with your providers has never been more important.
But, factor in the necessities of compensating members of the team for their role, of each side meeting its profit targets, and the competing priorities faced by often short-staffed offices, it should come as no surprise many health plan staff members and providers are left wondering how to make it happen.
How do we as a health plan balance the range of providers in our network? How can we ensure the employed doctor with a large integrated delivery system has his/her needs met while at the same time engaging the single-office practitioner and ensuring his/her goals are met?
Meeting the needs for each of these scenarios and others starts with how well defined our provider incentive programs are. Do they adequately support the clinical and financial goals of the plan and the provider? Have we built an incentive program that has achievable and actionable benchmarks?
Whether your providers are still fee-for-service (FFS) or at full percentage of premium risk, a few building blocks will ensure success:
- Healthcare Is Local: Have we done our benchmarking for incentive programs at the local/regional level to ensure we are measuring apples to apples and taken into account the local practice of medicine?
- Prioritization: Ensure Clinical, Risk Adjustment, Star Ratings, Claims, and Network Operations are all collaborating and prioritizing their "asks" of the providers and working together to ensure the needs of the providers are met.
- Education, Education, Education: By arming your leaders with the education necessary to purchase the best reporting tools, they are able to develop the goals and framework necessary for the frontline staff to educate and respond to providers.
- Support ICD-10 Effective Implementation: If the Centers for Medicare & Medicaid Services (CMS) predictions hold true, denial rates and outstanding receivables are likely to increase during the conversion. Despite testing and readiness efforts, it's entirely possible some providers may not be staffed or prepared to mitigate technology-related problems among their payers or to weather the longer-term reduced productivity of their coding staff. Before your providers can invest additional energy into documentation for chronic conditions and quality priorities, they've got to keep the cash flowing
- Data Validation Reviews: Data integrity starts with collecting and configuring the provider data at the start of the contracting and credentialing process and becomes critical for downstream health plan operations. For example, the inclusion of an incentive program for achieving data accuracy, timeliness, and integrity is a critical element in your risk adjustment work plan. Offering incentives for providers to achieve and maintain 95% coding accuracy on all diagnoses, meaning 95% of the diagnoses submitted by the provider that can be substantiated in the medical record, subject to a random validation review, can often become a path to shifting providers to more risk-based contracting. However, if your provider data is not correct or complete, the plan or its vendor can spend more time trying to find a provider than validate results.
- Focus on Actionability: Health plans often provide catalogs of reports each month showing providers numerous views of their panels and forget providers are taught evidence-based medicine and how to care for patients, not administrative functions. By telling providers to improve care, we can make them vulnerable and defensive. By collaborating to improve processes and coordination for better patient satisfaction and outcomes, we can let the providers be providers.
- Continuous Measurement, Re-Evaluation and Reward: While we naturally monitor our outcomes and re-evaluate our processes, we sometimes forget to reward ourselves for a job well done. We can build in contractual provider incentives, but peer recognition and a "thank you" are often simple but overlooked motivators.
In summary, there is no one straight line to navigate the path from FFS to pay for performance to risk for the plan or the provider, but there is one way to ensure success on that path — collaboration between the plan and the providers. By breaking down the silos and barriers, being transparent in our actions, and reporting, we can build the trust needed to ensure we are not "checking the boxes" on the incentive plan but rather seeing the success in better patient outcomes and lower expenditures.
Resources
GHG's multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Retail Healthcare - An opportunity for success
Are you providing your members and potential members the opportunity to speak with you in person?
In the age of technology, we are forgetting how to serve our customers without them having to pick up the phone or log into a website. For some, this way of doing business fits the population they serve. It's fast and convenient, but in the Medicare world, we still have customers who want to speak with us in person, who need help navigating the complexity of healthcare, and sometimes it just can't be solved by pushing a button on a phone or computer.
So how do health plans continue to evolve in the technology world and still provide a personal touch while remaining profitable?
If providing quality healthcare and outstanding customer service is the objective of a health plan, and members and potential members want services on their time, in their neighborhood, then a brick and mortar location can solve for both.
Brick and mortar locations — or storefronts — can be used as a multi-purpose space for health plan staff, agents/brokers, and the surrounding community. These stores can be strategically designed for year-round activity or be used as a pop-up location during open enrollment and provide numerous advantages that online cannot:
Year-Round Opportunity:
- Utilizing a variety of healthcare professionals such as medical groups and providers, senior associations, and ancillary community interaction at the store location.
- Provide informational seminars for both educational and sales purposes, health and wellness information, engagement with the local community, age-in seminars, and Medicaid eligibility clinics to help the low-income population apply for Medicaid/Low Income Subsidy (LIS).
Seasonal Opportunity:
- Facilitate sales seminars, lead agent appointments, walk-ins, and seasonal health fairs to drive Annual Election Period (AEP) awareness and educational seminars to bring awareness to the products and services offered by your health plan.
Achieving a measurable return on valuable marketing dollars goes a long way toward meeting growth objectives and improves profitability. With marketing budgets challenged by today's economic conditions, and the added pressure of Medicare Advantage rate reductions on health plan's cost structure and a shortened AEP, finding ways to maximize enrollment and spend less gets tougher and more challenging.
So whether your health plan is considering a year-round opportunity or seasonal location, this can bring your members and potential members a comfortable setting to gather, a place for the community to learn more about Medicare/Medicaid services, answer member questions, and troubleshoot issues pertaining to enrollment right in the heart of community — no dialing, no waiting — just fast and convenient.
Potential success with storefronts can be what your market needs, but careful design of a robust strategy is required to maximize your return on investment. Don't delay — Gorman Health Group can help you navigate the complexities and provide you with a plan that will surely satisfy your members, potential members, and your stakeholders.
Resources
At Gorman Health Group, we want to change the perception that member experience is the responsibility of Sales and Customer Service, instead showing organizations that member experience is a comprehensive approach with full transparency and cross-functional leadership. Visit our website to learn more >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Risky Business. Are You Ready for MACRA?
It turns out Uncle Sam has a plan. He tried mightily to bend that stiff cost curve. He threw everything he had at it — fixed prices, automatic reductions, sophisticated relative value schemes. He could not do it. Turns out the pen (or mouse) is mightier than the sword because almost all of the Medicare benefit spend flows with the ink (or electrons) that is released by the physician's hand. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a game changer like prospective payment system (PPS).
Humans are inherently risk-averse. Doctors are humans. This new Part B payment scheme is going to make them uncomfortable. The Medicare Merit-Based Incentive Payment System (MIPS) puts a percentage of Part B reimbursement at risk — a modest 43% initially, but it climbs quickly. The Centers for Medicare & Medicaid Services (CMS) estimates 88% of eligible practitioners will be feeling that in 2019. This year more than 200,000 doctors (roughly two in five) were penalized for failure to achieve meaningful use of electronic health records in performance year 2014. Many have decided to just accept the reductions like the person who collects parking tickets because it's just too much trouble to park in a lot.
Changes in the law can have unintended consequences. Prospective payment led to premature discharges from hospitals. The introduction of the physician fee schedule and sustainable growth rate targets led to an increase in the volume and intensity of services (or claims maybe). What will the consequences of MACRA be? Will the money at risk motivate physicians to be more efficient? Or will it lead them to shun traditional Medicare patients?
Yesterday, during a U.S. Senate Committee on Finance hearing on MACRA, CMS seemed to acknowledge the challenges of releasing the final rule for MACRA in November 2016, then measuring physicians immediately after that in January 2017 for 2019 payment basis. Clients and prospective clients should be aware that the potential delay recently discussed by the CMS Acting Administrator is not a delay of MACRA implementation. He referred to possibly delaying the start of the 'performance year' that will be used to adjust payments in 2019. The need to prepare for value based Part B payment is pressing, and those that prepare soonest can turn MACRA into an opportunity.
We have been talking to clients and friends around the industry. We are seeing a lot of interest in the alternatives to MIPS, that is the Alternative Payment Model (APM) approach. Those programs like Pioneer Accountable Care Organizations (ACOs) that take meaningful downside risk clearly have the potential for growth and profit, but they are not for the faint of heart. We believe for group practices and hospitals that bill for physician services, the middle road shows great promise. That alternative is to develop a Medicare Shared Savings Program (MSSP) ACO that avoids downside risk initially. This is a "Track One" ACO — it lets providers have less exposure to complex MIPS reporting and the opportunity to get ready for a potential launch into a higher risk approach later.
On July 7, 2016, CMS further solidified their commitment to MACRA (alternatively the Quality Payment Program (QPP) with the announcement of the proposed rule updating payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) starting January 1, 2017. CMS is proposing modifications to the MSSP to update the quality measures set to align with the proposed measures for the QPP, changes to take beneficiary preferences for ACO assignment into consideration, and changes that would improve beneficiary protections when ACOs are approved to use the skilled nursing facility (SNF) three-day waiver rule. The writing is on the wall — CMS will continue to move towards standardization of government-sponsored health plans via clinical and financial policy to ensure dollars spent meet the goals of improved beneficiary health, better population health management, and a trend of cost containment.
Every organization in the healthcare industry will be impacted by MACRA; some will be directly impacted, others impacted indirectly, and some will be affected by unintended downstream consequences of the legislation. Regardless of whether you are a health plan, a provider organization or a vendor that supports providers or health plans, we can help.
Our experts can review operations to identify risks and opportunities, increase integration within clinical and pharmacy programs, design well-coordinated activities across multiple healthcare programs, and ensure that your organization's infrastructure and tools are prepared for MACRA's impact on the industry. From in-depth analytics and tactical support to thought leadership and strategic planning, we can help. Contact our team today >>
Resources:
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Navigating the path to value. Elena Martin, GHG's Senior Director of Provider Innovations, outlines the MACRA quality payment program. Read now >>
Advancement in Analytics
It's all about the numbers! As the Centers for Medicare & Medicaid Services (CMS) tries to quantify more and more aspects of government-sponsored healthcare, metrics are a critical component.
Metrics are needed to measure quality programs, returns on investment in patient care, redistribution of staffing and financial resources, as well as benchmarking.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a perfect example of how CMS is pushing this financial focus. The past few years of shared savings models for Fee-for-Service members have evolved into very strict timelines and formulas that will directly impact the financial performance of providers in addition to the intended impact on improving member experience and quality of care.
As providers and health plans now have to walk this tightrope of real and projected results with multiple stakeholders (regulators, health plans, providers, members, and third parties), the necessity of analytics and good internal reporting are now of utmost importance.
The best tool to manage these priorities and resources is to have a solid reporting mechanism. Whether you are a start-up or an existing organization, the need for an integrated data repository cannot be ignored. Multiple vendors can help with specialized needs like population health or customized provider scorecards, but the sources have to be integrated. For a provider, this means to coordinate efforts with vendors and multiple health plans or payers. For a health plan, this means to coordinate efforts with vendors and payers as well as from within the health plan organization. Once the data is normalized and complete, reports and dashboards can be built, but keeping an eye on the whole organization is critical to recognize trends as they occur. The "whack a mole" analogy is appropriate — if you focus on one area, you might see improvement, but another area could suffer. You have to look at all areas.
We understand systems must be integrated to help identify actionable strategies. A gap analysis might be needed to assess organizational issues, procedures for reviewing the data to identify problems and their solutions, as well as timing — once a year budget variance reports will not be sufficient. Deep dives into specific problem areas are also critical — making sure you are looking for outliers (regardless of overall performance). Even if the organization does not change, the providers and members and regulations will change. This is a constant effort.
Recognizing the industry will spend nearly $600 billion on healthcare technology by 2020, we have built external, strategic partnerships, facilitated the development of internal solutions, and staffed a team of industry leaders to address this market trend in analytics. Our niche division cannot only connect Gorman Health Group clients with the solutions that are the best fit for their organization, the Healthcare Analytics team can ensure the governance of exiting systems and the investments in new technology are both implemented and optimized.
Let us help you keep your eye on the numbers and find solutions that will bring a return to satisfy all stakeholders.
Resources
On June 7, 2016, Daniel Weinrieb, Gorman Health Group's (GHG's) Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions and colleagues, David Sayen, Senior Vice President of Client Relations and Melissa Smith, Senior Consultant, recapped the details of the MACRA proposal and how these changes will affect providers, health plans, the care delivery system, and patients. Download the webinar recording here >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Is Your Sales Distribution Strategy Up for the Challenge?
It's already July, and time is ticking! Do you have your sales distribution strategy completed and management staff in place? With the Annual Election Period (AEP) just a few months away, finalizing your distribution channel, creating sales training, developing telemarketing scripts, and hiring management to oversee all these tasks must be completed now. In addition, making sure you have compliant marketing materials and a compliant website is more important than ever.
Make sure you have done the following:
- Develop sales recruitment strategies that align with your sales and retention goals
- Identify Field Marketing Organizations that fit your culture and believe in your value proposition
- Identify obstacles or gaps within your Sales team
- Develop sales goals that promote year-over-year growth
- Confirm the proper number of agents are in place to meet sales goals
- Verify you have a sales oversight program that will hold up to the Centers for Medicare & Medicaid Services (CMS) standards
- Create trainings that help your sales staff:
- Sell against the competition
- Develop key alliances in the community
- Navigate the dos and don'ts of marketing
- Conduct community meetings
- Self-generate leads and community outreach
- Telemarketing implementation plan — whether internal or external resources are being utilized
- Sales scripts for Telemarketing team that are ready to be submitted to CMS' Health Plan Management System for review
• Have strong call center staff development scheduled
• Update policies and procedures for Sales and Member Services based upon internal goals and 2017 Medicare Marketing Guidelines (MMG)
• Review marketing materials and your website to make sure they are compliant
If you feel overwhelmed by this list, don't worry — our Sales and Marketing subject matter experts can help you maneuver through the overwhelming task of hiring, training, and implementing strategies while navigating your Sales management staff through the newly released 2017 MMG. We can even provide you with proven interim staff to get you on track for the 2017 AEP.
Our goal is to help you succeed and achieve your 2017 AEP sales goals. Let us weather the storm for you while you watch your membership grow. Don't let time run out — contact us today!
My favorite quote:
"Sometimes I wish I could just fast forward the time just to see if in the end it's all WORTH IT!"
— Author Unknown
Resources
Impact of the 2017 Medicare Marketing Guidelines. On June 10, CMS announced the release of the 2017 Medicare Marketing Guidelines (MMG) for Medicare Advantage Organizations (MAOs) and Part D Sponsors. In a new article, our teams of Compliance and Sales & Marketing experts outline the top changes to the guidelines that we believe will have an impact on your organization. Read now >>
Gorman Health Group's Sales Sentinel™ is a flexible, module-based software solution with the ability to onboard agents, provide training, manage ongoing oversight activities and pay commissions. Created by GHG, Sales Sentinel™ was designed to address the specific needs of government managed care organizations. Request a demo today >>
Why Is Conducting a Part D Operational Assessment so Important?
Medicare Part D is a complex program that is continually in motion. The Centers for Medicare & Medicaid Services (CMS), in an attempt to provide clarity to stakeholders, actively publishes updated guidance to sponsors to assist in process improvement and encourage optimal beneficiary outcomes and experience. Keeping up with Health Plan Management System (HPMS) memos, best practices, yearly call letters, and webinar information is challenging. Dynamic and ever-changing guidelines inevitably bring uncertainty and risk. Understanding these guidelines and operationalizing a compliant program is key to a successful program and financial sustainability.
For an organization to succeed in this fluid environment, it must achieve higher quality and Star Ratings, improve beneficiary satisfaction and retention, while staying on top of compliance and operational efficiency. CMS expects all plan sponsors to carefully and regularly evaluate risks to their organization. Emphasis is placed on compliance, identification and prevention of fraud, waste, and abuse (FWA), and oversight of first-tier, downstream, and related (FDR) entities. Additionally, in recent years, there has been increased focus on coverage determinations, appeals, and grievances. All of these areas can have an impact on a plan's Star Ratings and financial outlook.
Conducting a comprehensive operational assessment is an excellent strategy to identify a plan's strengths and weaknesses and evaluate the adequacy and reliability of operations. Information is gathered and evaluated from multiple sources such as current policies and procedures, oversight activities, reports, and operational processes. Comprehensive evaluation of this information will proactively identify areas of risk, allowing plans to strategically adapt to the changing environment to reduce identified risks. Gorman Health Group, with our team of industry experts, can provide an assessment of areas of greatest risk exposure along with solutions based on best practices, ensuring the organization is well positioned for future success.
Resources
Our broad array of services can assist you in post-audit remediation, implementation of best practices, PBM contracting and implementation, interim staffing, clinical process re-engineering, Star Ratings improvement, and claims and PDE assessment and adjustments. Visit our website to learn more about our Part D services >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Medicare Program Audits — Four Things Operations Should Be Doing Today
Do you think the Centers for Medicare & Medicaid Services (CMS) program audits are stressful? We often make it worse for ourselves than it already is. Imagine being in the audit webinar pulling up a case and having CMS say that case was to be excluded from the universes. Instead of showing your department, processes, and system capabilities, CMS is getting the impression you don't even know your data well enough to pull a correct universe. What can Operations departments do to get ready? Here are four things you can begin doing today to be ready:
- Set up automated universe pulls, both with internal systems and delegates. Automating these processes will allow you to pull them quickly and use them on a regular and ad hoc basis. Additionally, automating the process will help you identify which fields are not being captured properly or at all in your system. This can be the biggest difficulty in pulling universes and not something you want to find out when you receive your CMS audit notice. Start this process today.
- Learn to use the data in the CMS audit universes. CMS uses these formats for a reason. CMS has fine-tuned this process to allow them to most readily identify outliers and potential issues. This will help you as you monitor your own operational departments and identify hidden trends. It will also help you regularly monitor your delegates.
- Set up time to complete mock audits of the potential outliers. Pick 10 sample outliers on a monthly basis to review to determine if there are issues with your processes or universe pulls. It makes sense to do this within each operational area internally. You should know what is happening within your department before anyone else identifies it; this includes members, Compliance, or CMS. You will be surprised what you will learn through this review.
- See it to the end. Think like CMS when you complete your reviews. Put aside your thoughts on system limitations and department politics and how many times you have tried to address an issue. How does what you find impact members? How does this follow guidelines? If you identify issues, complete the process by running a beneficiary impact and root cause analysis. This will let you know scope and give you the information you need to address the issue. This may be supplying the information to allow a prioritization of a fix you haven't been able to get prioritized before.
When we in Operations see CMS audits as something that is managed by Compliance, we do ourselves a disservice and lose out on one of the most valuable tools we should all have in place. Implementing these processes will change the dynamics of your department, promote ownership, and make a live CMS audit easier.
The Gorman Health Group Operational Performance practice consultants have been in your shoes. We have faced the multiple priorities and pressure to meet production goals and maintain team satisfaction at the same time. If you need assistance in setting up an audit-ready department, we can help.
Resources
At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Click here to learn about GHG's Operational Performance services >>
Gorman Health Group has decades of experience stress-testing hundreds of operational business units and can assist with implementing CAPs post-audit or in proactively addressing operational problems before regulators come knocking. Visit our website to lean more >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
The Evolution of Healthcare.gov — It's Time to Play Ball!
Now that the Federally-Facilitated Marketplace (FFM) is paying Issuers directly from the FFM system versus the Issuer's system, we are participating in a different type of ball game. Issuers now need to shift gears and begin thinking about how they can impact a timely and accurate payment of Advanced Premium Tax Credit (APTC), Cost Sharing Reduction (CSR), and User Fee (UF) charges. Two key areas are at play here: the reduction in tracked discrepancies and ensuring action is taken to resolve and apply consumer data corrections to the FFM system to be in sync. As Issuers react to the May payment cycle and prepare for June payment, they are beginning to think about their overall payment strategy from this point on.
When considering the Issuer's role, the days of not establishing the necessary resources to research and resolve all discrepancies simply because the volume is too high will not suffice during an audit or bring revenue in the door either. So when we talk about an overall payment strategy, it is important for Issuers to recognize they are playing on the team responsible for tracking, fixing, and overseeing their reconciliation program, which includes building an expected payment and outstanding payment based on data cleanup that is pending.
Bringing transparency to the FFM model is the first step towards alignment of data between the Issuer and the FFM and true reconciliation. Imagine being able to discuss with your government partners the substantial payment impact your organization is experiencing simply because the FFM has not applied all outstanding data corrections. That phenomenon is actually occurring today. Since January 2016, the FFM suspended the application of field-level corrections to the FFM system until this month. Issuers should finally see six months of updates reflected in their July payment and are working towards quantifying what that impact will be.
As the FFM model continues to evolve, Issuers are still working towards solving their own challenges:
- Lack of strategy for timely and accurate payment of APTC, CSR, and UF charges
- Unmanageable volume of discrepancies and inability to prioritize
- Backlog of submitted disputes and delays with the Marketplace updating system corrections
- Struggling with measuring and managing the chaos
- Missed revenue opportunities
- Not audit ready
Based on the importance of being in sync with the Marketplace — both FFM and State-Based Marketplaces (SBMs) — Gorman Health Group (GHG) has launched a new reconciliation service with a focus on reducing the volume of enrollment and payment discrepancies while building best practices within Issuers' Finance and Enrollment departments. Now that discrepancies represent real dollars, the stakes are high.
Through GHG's Marketplace reconciliation services, Issuers will be able to track and resolve enrollment and payment discrepancies and quantify the financial impact of those reconciliation efforts. GHG's reconciliation experts will equip Issuers with the knowledge to predict their payment (prospective and retrospective) each payment cycle and build a process to react when the actual payment is not what your organization expected, either through a submitted dispute or internal update.
Our proprietary tool, Valencia™, which currently reconciles 42 percent of the 12.7 million Marketplace enrollees, supports clients' reconciliation processes with a comprehensive approach. Aside from managing enrollment and payment reconciliation, Valencia™ provides compliant and transparent workflow to ensure your operational processes — and the resulting payment — are as accurate as possible. Our goal is to help Issuers manage the chaos and be audit ready.
To learn more about the GHG's reconciliation services, and how they support enrollment and payment reconciliation for Issuers, please contact ghg@ghgadvisors.com.
Resources
Gorman Health Group has launched a new reconciliation service with a focus on reducing the volume of enrollment and payment discrepancies while building best practices within Issuers' Finance and Enrollment departments. Now that discrepancies represent real dollars, the stakes are much higher. Visit our website to learn more >>
With Gorman Health Group's Valencia™, you'll always know where your membership and premium-related data is out of sync, thus eliminating missed revenue and inappropriate claims payments. You'll also have complete control of rigorous, compliant and transparent workflow controls that complement your enterprise system. Set up a demo today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Medicare Marketing Guidelines Summary of Changes — Have They Left You Scratching Your Head?
On June 10, 2016, the Centers for Medicare & Medicaid Services (CMS) announced the release of the 2017 Medicare Marketing Guidelines (MMG) for Medicare Advantage Organizations (MAOs) and Part D Sponsors.
Added language, clarification, and new requirements seem to be the theme with the recent updates. So how do these changes affect business as we prepare for the 2017 Annual Election Period (AEP)?
At Gorman Health Group (GHG), our team of subject matter experts comes together to provide you with clarification around a few key changes from the final MMG Summary of Changes and recommendations for your organization.
Marketing — Diane Hollie, Senior Director of Sales & Marketing Services, says, "Although CMS has stipulated provider and pharmacy directories are considered non-marketing material, it doesn't mean the provider directories don't get submitted to CMS. In fact, all plans must submit their hard copy provider directories to CMS on an annual basis."
CMS is now referring Sponsors to the Medicare Managed Care Manual, Chapter 4, for provider directory guidance and the Prescription Drug Benefit Manual, Chapter 5, for pharmacy directory guidance — making it a more complicated process. The following are just a couple of provider directory rules found in Chapter 4, which were announced earlier this year in a 4/28/16 Health Plan Management System (HPMS) memo.
- All hard copy directories must be uploaded into HPMS as a non-marketing material under the XXX submission code.
- All hard copy directories must be uploaded prior to making the directory available by September 30.
- Because provider directories are considered non-marketing, MAOs should not include a status after the material ID.
- To distinguish the provider directories as non-marketing, the following material ID should be used: plan's contract number, followed by an underscore, followed by a series of alpha numeric characters chosen at the discretion of the plan, followed by an underscore, followed by the letters "NM." Example: HXXXX_ABC124_NM
While it is noted the MMG has referred readers to the PDBM, Chapter 5, for pharmacy directory guidance, there is no cross-referenced information. This could be an indicator a revised Part D Chapter 5 will soon be released. Without it, Sponsors will be left scratching their heads.
Sales — Carrie Barker-Settles, Director of Sales and Marketing Services, understands the importance of agent/broker oversight and Sponsor sales activities. "Helping plans/Part D Sponsors and agent distribution channels navigate the dos and don'ts of the rules and regulations can be very overwhelming, but at GHG, we can make that challenging task less daunting for both."
Below are just some of the changes relating to sales oversight:
- Telephonic Contact — Plans/Part D Sponsors may call their current MA and non-MA enrollees or use third parties to contact their current MA and non-MA enrollees about MA/Part D plans. Examples of allowed contacts include calls to enrollees aging into Medicare from commercial products offered by the same organization and calls to an organization's existing Medicaid/Medicare-Medicaid Plan (MMP) enrollees to talk about Medicare products. The updated guidance clarifies, when discussing Medicaid products, Sponsors must follow all applicable Medicaid marketing rules. Plans/Part D Sponsors, sellers, and telemarketers may conduct these telephonic activities, but we recommend you fully understand all the regulations for both unsolicited and solicited contact before reaching out to Medicare beneficiaries.
- Compensation Payment Requirements — Whether you use employed, captive, and/or independent agents, you must inform CMS yearly by the end of July which channels you will be using as well as the compensation payment rates or ranges. The compensation structure must include:
- How the Plan/Part D Sponsor intends to disseminate compensation, specifying payment amounts for initial and renewal compensation.
- CMS has clarified in the revised guidance the compensation structure must stay the same for the compensation year that was put in place by October 1.
- How the Plan/Part D Sponsor intends to disseminate compensation, specifying payment amounts for initial and renewal compensation.
Some Plan Sponsors may have already been following this process, but if not, yearly requirements outlined in the MMG suggests all Plan Sponsors check policies and procedures to ensure they adhere to their clarification.
"I come from a trust but verify world," says Regan Pennypacker, Senior Vice President of Compliance Solutions," and when the updated MMG is released, it's important Compliance teams disseminate the document to ensure affected business units can determine impact." "It's also important," she states, "to reconcile and ensure supplemental memos and clarification emails sent between revisions have also been rolled into the new guidance." For example, the Part C aspects of the August 13, 2015, "Clarification of CY2016 Medicare Marketing Guidelines" has indeed been rolled into the MMCM, Chapter 4, but as noted above, the Part D aspects pertaining to pharmacy directories has not. "This means plans will need to continue to reference that memo to ensure they are following the guidance as it pertains to pharmacy directories."
"Overall," states Regan, "it will be important for Compliance to partner with Sales and Marketing staff to ensure adherence to all changes and clarifications."
We have highlighted just a few of the key changes, but to learn more, register to join our upcoming webinar on June 28, 2016, from 1 - 2 pm ET.
Resources
Once you have your PBPs in place (we can help with that, too), our teams can develop or review your sales collateral and creative by product type to help ensure your high-impact messaging is both targeted and compliant. Visit our website to learn more >>
Gorman Health Group's Sales Sentinel™ is a flexible, module-based software solution with the ability to onboard agents, provide training, manage ongoing oversight activities and pay commissions. Created by GHG, Sales Sentinel™ was designed to address the specific needs of government managed care organizations. Request a demo today >>
The MSSP Final Rule
On June 6, 2016, the Centers for Medicare & Medicaid Services (CMS) released the final Medicare Shared Savings Program (MSSP) Rule, making some significant improvements to the MSSP program. The two notable changes are the use of regional factors when resetting Accountable Care Organizations' (ACOs') benchmarks and a new incentive to transition to the two-sided risk model. These new changes will no doubt help retain existing participants as well as help move some participants into tracks with risk-sharing arrangements.
A significant change, which the industry has been pushing for, is the use of regional Fee-for-Service (FFS) spending rather than national spending data to adjust cost benchmarks in the second or subsequent contract year period. Participants have long argued that success is not properly assessed because participants are currently measured against their own past performance rather than other providers in the same region. Thus, successful ACOs are potentially penalized in future years, while poor performing ACOs realize greater rewards.
CMS will use a phased-in approach to transition to the regional adjustment, with a weight of 35% applied the first year, moving to 70% the second year. CMS also addressed comments on ACOs who may currently have higher spending than their region by allowing for a slower phased-in approach. Initially, the weight placed on the regional adjustment will be 25% in the first agreement period and will increase to 50% in the second agreement period and 70% in the third agreement period.
An ACO's regional service area will be determined by the counties of residence of the ACO's assigned beneficiary population. The regional service area will include any county where one or more assigned beneficiaries reside.
CMS will continue to establish the first year historical benchmark based on Parts A and B FFS expenditures for beneficiaries who would have been assigned to the ACO in each of the three years prior to the start of the ACO's agreement period. However, CMS will now only use assignable FFS beneficiaries for the calculation rather than all FFS beneficiaries.
CMS is also trying to give more incentive to move into Track Two, with downside risk, by allowing for a phased-in transition. CMS will now allow participants to move into Track Two but provides for an additional fourth year of one-sided risk.
CMS did decline to provide an accelerated path into a two-sided track for contracts currently under Track One, which will prevent them from meeting the criteria for advanced alternative payment models (APMs). Because the performance period begins in 2017, these APMs that will be in the second or third year of their agreement period will miss out on bonus payments for 2019.
As of January 2016, there were over 400 ACOs participating in the shared-savings program, serving more than 7.7 million beneficiaries. Most of these are still under Track One, which does not include downside risk. Coupled with the new incentives under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Systems, for which the performance year begins January 2017, organizations should take a good look at the opportunity of taking the plunge into ACOs.
Resources
We understand Medicare ACOs: We have helped launch seven or eight over the past two years. But we also understand that this is just a first step toward taking greater control over the Medicare revenue stream by "moving up the food chain." Our team of veteran executives can help your ACO evaluate the options, manage the workflow to achieve either a Medicare Advantage contract with CMS or a risk contract with an existing MA plan, and continue to achieve improved outcomes Visit our website to learn more >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>